Should antivirals be used in Guillain-Barré Syndrome (GBS)?

Antivirals Should Not Be Used in Guillain-Barré Syndrome

Antivirals are not recommended for the treatment of Guillain-Barré Syndrome (GBS) as they have no proven benefit and may potentially cause harm.

Understanding Guillain-Barré Syndrome

Guillain-Barré Syndrome is an acute peripheral neuropathy of autoimmune origin characterized by:

• Progressive weakness in the limbs evolving over days or up to 4 weeks
• Often triggered by a previous bacterial or viral infection
• Autoimmune attack on peripheral nerves

Evidence-Based Treatment Recommendations

First-Line Treatments

1. Intravenous Immunoglobulin (IVIG):

   • Recommended dose: 0.4 g/kg body weight daily for 5 consecutive days (total dose of 2 g/kg)
   • Should be initiated within 2 weeks of symptom onset 1
   • First-line therapy for most patients, including children and pregnant women

2. Plasma Exchange (Plasmapheresis):

   • Equally effective as IVIG in terms of clinical outcomes
   • Requires specialized equipment and has a higher complication rate 1, 2
   • Recommended for nonambulant adult patients within 4 weeks of symptom onset 2

Treatments NOT Recommended

1. Antivirals:

   • No evidence supports their use in GBS
   • The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine prescription of antivirals for conditions without documented efficacy 3
   • May cause adverse effects including nausea, vomiting, photosensitivity, and rarely, neurological reactions 3

2. Corticosteroids:

   • Not recommended for GBS management 1, 2
   • No proven benefit and may have negative effects

3. Combined Therapy:

   • Sequential treatment with plasma exchange followed by IVIG is not recommended 2
   • No additional benefit over either treatment alone

Respiratory Monitoring and Management

Critical respiratory parameters to monitor (the "20/30/40" rule) 1:

• Vital Capacity < 20 ml/kg
• Maximum Inspiratory Pressure < 30 cmH₂O
• Maximum Expiratory Pressure < 40 cmH₂O

Consider ICU admission for patients with:

• Evolving respiratory difficulty
• Severe autonomic dysfunction
• Swallowing difficulties
• Rapidly progressive weakness

Special Considerations

Patients with History of GBS Following Vaccination

• For patients with a history of GBS within 6 weeks of previous influenza vaccination, antiviral chemoprophylaxis may be considered as an alternative to vaccination 3
• This is a specific preventive measure for influenza, not a treatment for GBS itself

COVID-19-Related GBS

• Standard GBS treatments (IVIG, plasma exchange) should be considered
• Intravenous immunoglobulin treatment alone has not been shown to improve outcomes or mortality in COVID-19-related GBS 4
• More research is needed for specific approaches to COVID-19-related GBS

Prognosis

• Generally favorable but variable
• Mortality rate approximately 10%
• About 20% of patients are left with severe disability 1
• Greatest recovery occurs in the first year but may continue for over 5 years
• 85% of patients have residual symptoms such as fatigue and pain 5

Emerging Treatments

Current research is exploring:

• Adjusted IVIG dosages based on prognostic factors
• More specific immunomodulation, including complement inhibitors 5, 6
• Neuroprotective interventions 6

These emerging treatments highlight the need for more effective therapies, but none have yet replaced the established treatments of IVIG and plasma exchange.